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This on-line order form is for exclusive submission to 
Portamedic-Wilshire Branch only.


This form is for A.P.S. requests only.
For other requests, please click here


Please provide the following agent information:

Agent Name:

Insurance Company:
Agency Name/Code:

Ordered By:

Order Date:

(mm/dd/yy)

Phone (area code & #):

 

FAX (area code & #):

E-Mail (for follow-ups):

Records pertain to:

Applicant Name:

A.K.A.:

Applicant Telephone (area code & #):

Date of Birth:

(mm/dd/yy)

Patient/Member Number:

Please identify location of records:

Doctors/Hospital Name:

 

Doctors/Hospital Address:  
Doctors/Hospital Phone:  

PLEASE FOLLOW THESE INSTRUCTIONS WHEN ORDERING A.P.S.:
1.  Be sure to send or fax us applicant's consent to release medical records.
2.  Full name of the doctor/hospital, address and phone number.
3.  If patient is a member of Kaiser or FHP, be sure to include their membership number.
4.  If patient has been seen by a doctor through military service, be sure to include social security number.
 

Please enter important notes or special instructions here:


Thank you!


 


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